Provider Demographics
NPI:1588863351
Name:LOPES, GUSTAVO (DO)
Entity type:Individual
Prefix:DR
First Name:GUSTAVO
Middle Name:
Last Name:LOPES
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 20800
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4105
Mailing Address - Country:US
Mailing Address - Phone:888-402-7256
Mailing Address - Fax:888-902-1099
Practice Address - Street 1:900 SE BECKER RD
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34984-6641
Practice Address - Country:US
Practice Address - Phone:772-255-7550
Practice Address - Fax:561-626-9804
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-12
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS10182208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004291000Medicaid
FLEP099Medicare PIN